The Lesion

Dr. Ian Carr

Professor Emeritus, Faculty of Medicine, University of Manitoba

This presentation is intended to illustrate to medical students the history of our knowledge of disease processes by describing the evolution of our knowledge of the lesion, the local tissue change which accounts for change in bodily function, locally or systemically. This functional change may be accompanied by disease, the patient's awareness of disturbance from the normal. The history of the investigation of disease is a history of attempts to find out where the abnormality is, and to classify it, first in words, then in words and pictures of grossly abnormal organs, more recently by microscopic, and biochemical investigation.

Early Ideas on the Lesion

Early writings, statues and votive offerings show that the idea of local tissue change came very early. An ancient Mesopotamian sculpture, dated about 3000 BC depicts a lion with an arrow in the spine, and evident paraplegia. Carcinoma and "schirrhus" were described in the Hippocratic writings. Celsus described several pathologic changes, for instance enlargement of the spleen. Galen described tumores praeter naturam and there were repeated analogies between a neoplasm and a crab.

After the Dark Ages, isolated autopsies occurred as early as 1302, for forensic purposes. There was however considerable reluctance to dissect the human body, for religious reasons. This reluctance was set aside by the famous decision of the Faculty of Theology at the University of Salamanca in 1556:

The dissection of human corpses serves a useful purpose, and is therefore permissible to Christians of the Catholic Church.

Thereafter, more and more often, autopsies were carried out by physicians to find out why their patients had died, or when people died in suspicious circumstances.

Antonio Benivieni (ca. 1443-1502)

Antonio Benivieni, a Florentine, practised medicine in his native city for over thirty years, and kept methodical records, including brief accounts of a score of autopsies, for instance on a case of carcinoma of the stomach. His records were edited after his death, and published as De Abditis...Morborum..Causis. The autopsy accounts are brief, but the book is clearly the forerunner of the great pathology texts.

Case xxxvi: Hardening of the Stomach

My kinsman, Antonio Bruno, retained the food he had eaten for too short a time and then threw it up undigested. He was most carefully treated with every kind of remedy for the cure of stomach trouble, but as none was of any use at all, his body wasted away through lack of nourishment till little more than skin and bone remained. At last he was brought to his death.

The body was cut open for reasons of public welfare. It was found that the opening of his stomach had closed up and it had hardened down to the lowest part with the result that nothing could pass through to the organs beyond, and death inevitably followed.

Such investigations were interdependent with the revitalization of the study of human anatomy, carried out by dissection of the normal human body , as part of medical education. This revitalization is epitomized by the De Humani Corporis Fabrica, (1543) of Andreas Vesalius, Professor of Anatomy and Surgery at Padua.

Giovanni Batista Morgagni (1682-1771)

Giovanni Batista Morgagni was born at Forli in Italy, and trained in medicine at the University of Bologna. He became Professor of Practical Medicine at Padua in 1711, and later Professor of Anatomy. His professional life was spent on the practice of medicine, and the study of normal and pathologic anatomy by the post mortem dissection of patients whose disease he had often followed in life. His great book was published when he was 79 years of age.

De Sedibus Causis Morborum, Venetia, 1761

A man of about fifty-four years of age, had begun , five or six months before, to be somewhat emaciated, in his whole body....a troublesome vomiting came on of a fluid which resembled water tinctured with soot.

In the stomach, towards the pylorus, was an ulcerated cancerous tumour, and this seem'd to be made up of congeries of glands which being pressed , discharged a kind of humour like the male semen. And the stomach contained three pints of a matter, almost of the same nature with that , which was thrown up by vomiting.

Betwixt the stomach and the spleen were two glandular bodies, of the bigness of a bean, and in their colour and substance, not much unlike that tumour which I have described in the stomach.

Morgagni described lesions and related them to the course of the disease.

Matthew Baillie (1761-1823)

Matthew Baillie was a nephew of the Hunter brothers, and was trained in medicine in the University of Glasgow. He taught anatomy with William Hunter from whom he inherited the use of his museum, and the ownership of the Anatomy School on Great Windmill St., London. His book The Morbid Anatomy of some of the most Important Parts of the Human Body was first published in 1793, went into ten English editions, and was widely translated. The illustrations,m The Series of Engravings, were published separately, from 1799-1803.

A new edition of these has recently been produced by Professor Harold Attwood of the University of Melbourne, from a copy rescued in 1953, from the flooded basement of the old medical library.

Baillie was physician to St. George's Hospital, London, and spent the latter part of his life in a lucrative clinical practice in London, and as physician to George III.

Baillie published clear illustrations of lesions as seen in the autopsy room.

John Hunter (1728-1793)

John Hunter was born at Long Calderwood, Lanarkshire, Scotland, the youngest of ten children, when his father was seventy years old. His formal education was scant, but after service in the army, he became a well known teacher of Anatomy in London. His collection of specimens was the basis of two famous museums. He was surgeon to St. George's Hospital and a Fellow of the Royal Society. His army service led to an interest in gun shot wounds, and inflammation, and in the long run to his famous work, A Treatise on Blood, Inflammation and Gunshot Wounds, published a year after his death. This text contains his classic observations on inflammation. While these observations were not individually new, he emphasized the principles that inflammation was a general phenomenon, with stages, which might resolve, or progress and suppurate. He stated clearly that "the extravasated fluid in inflammatory oedema was water, and that there were constitutional effects," although he believed that "fever was often the cause of local inflammation."

His picture of the early vascular changes was clear:

The very first act of the vessels when the stimulus which excites inflammation is applied, is, I believe, exactly similar to the blush.

Hunter described the lesion of inflammation in several phases and variants.

Marie Francis Xavier Bichat (1777-1802)

Francis Xavier Bichat, the son of a physician, was born at Thiorette in the French Jura, and studied at Montpellier, Lyons and Paris, where he later taught, and was physician to the Hotel Dieu. He conceived the idea of the "tissues" of the body, existing in various organs and susceptible to disease in various ways.

The membranes have not hitherto been a particular object of research among anatomists....We may distribute the simple membranes into three general classes....mucous...serous ...and fibrous.

Bichat analyzed the organs of the body into tissues, and suggested that these tissues were the basis of lesions.

Astley Paston Cooper (1768-1841)

Astley Paston Cooper was born near Norwich, and trained in medicine at Edinburgh. He was on the staff of both St. Thomas' and Guy's Hospital, and was a diligent, successful surgeon, popular as a teacher--despite the fact that his marriage to an heiress had rendered him financially independent. In llustrations of Diseases of the Breast, Part 1 (London, 1829), Cooper described inflammatory and innocent tumours of the breast, and gives one of the earliest descriptions of hyperplastic cystic disease of the breast (fibroadenosis).

Cooper illustrated surgically removed lesions, and pointed out the difference between benign and malignant lesions of the breast.

Carl von Rokitansky (1804-1878)

Carl Rokitansky was born at Koniggratz, and studied medicine in Prague and Vienna. He spent his life as pathologist to the Allgemeines Krankenhaus in Vienna. Rokitansky was a great descriptive pathologist; his pathology was gross pathology as seen with the naked eye. He gave early detailed descriptions of arterial disease, congenital cardiac lesions, and massive hepatic necrosis. His autopsy technique was widely followed, and he is alleged to have performed 30,000 autopsies.

Despite his anatomical bias, Rokitansky had a curious fondness for humoral ideas: "Humoral pathology is simply a requirement of common practical sense."

His ideas on aetiology sometimes read strangely to the modern ear: "The crasis which gives rise to the production of cancer consists mainly in a preponderance of albumin."

Rudolf Virchow (1821-1902)

Rudolf Virchow born in Pomerania, and educated at the University of Berlin, was Professor of Pathology at Wurzburg and then Berlin.

His major contribution was the idea that pathologic reactions were reactions of cells. As well as pathologist, teacher and experimenter he had a great interest in physical anthropology, in public and industrial health, and in archaeology. He also served in the Reichstag, and vigorously opposed Bismarck.

Virchow showed that lesions were composed of cells.

Julius Cohnheim (1839-1884)

Julius Cohnheim was born at Demmin in Pomerania, and trained in Wurzburg and Berlin, being latterly a pupil of Virchow. He was successively Professor of Pathology in Kiel, Breslau and Leipsic. His major contributions were in experimental pathology, and in particular in demonstrating that inflammation was an active dynamic process. He described the diapedesis of leucocytes as follows:

In the veins..the originally plasmatic zone becomes filled with innumerable colouless corpuscles...A pointed projection is seen in the external contour of the vessel wall..this grows longer and thicker, throws out fresh points, and gradually withdraws itself from the vessel wall, with which it is at last connected only by a long thin pedicle. Finally ...there lies outside the vessel ..a colourless blood corpuscle.

William Boyd (1885-1979)

William Boyd trained in medicine in Edinburgh and was Professor of Pathology successively in the Universities of Manitoba, Toronto and British Columbia. He wrote textbooks which related clinical; disease to autopsy findings in lucid readable English. These books were popular world-wide as undergraduate and post-graduate medical texts, and helped to give the Manitoba Medical School an international reputation in the 1930's.

It has become the fashion to regard morbid anatomy both gross and microscopic as somewhat of an outworn creed, a science as dead as the material with which it deals. But morbid anatomy is not dead, and never has been except in the minds of those whose dull minds would take the breath from the most vital subjects.